Collaborative article teaches payor audience about reimbursement challenges for ostomy supplies

About the Article

A recent collaboration of industry is bringing to light some challenges for consumers with ostomies when faced with decreased reimbursement of their medically necessary ostomy supplies.

Contributors were American Association for Homecare, United Ostomy Associations of America, Inc, United Spinal Association, Wound Ostomy and Continence Nurses Society, Wound, Ostomy and Continence Nursing Certified Board.

Read the full white paper here:  AAH Ostomy White Paper FINAL 08 17 21 (aahomecare.org)

Key points in the article:

  1. Patient choice should be protected, and supplies should not be substituted by the DME/HME providers without the patient's consent. Often a patient’s body and stoma profile are unique and may require specially fitting supplies.
  2. Payors who are not following Medicare fee schedules and do not update their own fee schedules risk putting the patient in a tough situation. Not all DME and HME dealers will accept reimbursement on ostomy pouches. With these opposing forces, patients may face larger than necessary out of pocket costs. 
  3. If patients are forced to switch product lines, they risk experiencing a poor fit, leakage and ultimately skin complications which could lead to additional healthcare utilization (clinic visits, ER or Readmissions to the hospital).
  4. It is well accepted that a proper fitting ostomy pouch can prevent leakage and skin complications and may improve outcomes. All payors should consider the cost of prevention vs the cost of readmissions and ER visits when deciding on fee schedules for appliances.
  5. Care coordination and product assessments can help improve outcomes through patients staying in properly fitting appliances. Education by suppliers and manufacturers assist not only the end-users but home care nurses as well.

What should you do?

Clinician/prescriber reader should:

  1. Continue to prescribe the products most appropriate for the patient needs using Dispense As Written
  2. Advocate for the patient if the payor’s fee schedule is insufficient by demonstrating the medical necessity for the recommended product
  3. Refer the patient to a dealer who will honor their prescription rather than switching patients out of the recommended product
  4. Enroll patients in manufacturers patient support programs and request follow up information on the patient satisfaction with the product

Payor reader should:

  1. Familiarize themselves with cost and incidence of ostomy related complications that may be reduced with the proper product and patient support
  2. Take a patient-centric long-term approach in determining adequate fee schedules
  3. Consider total cost of care including mental health when considering narrowing the DME provider network or a reduction in the fee schedule
  4. Increase the fee schedule to the Medicare level

Patient reader should:

  1. Be aware of the ostomy patients’ rights developed by UOAA and the right to use the product of their choice if supported by the clinician recommendation
  2. Complain to their clinician, ostomy supplier and their insurance company if they are dissatisfied with the product or service
  3. Join a patient support organization and support advocacy with the payors and policy makers at the state and federal level

Coloplast® Care ostomy advisors are available to help with product availability and questions – between acute and home health care and identifying dealer options for product supplies based on insurance. The Coloplast Care program also provides ongoing self-assessment tools, quality of life guidance (including setting up routines and instructions for use) and even ongoing support group webinars.

Payors should look at complimentary patient product and lifestyle support programs provided by manufacturers to see if there are documented outcomes. With Coloplast Care, a large study has shown lower healthcare utilization (readmissions and ER visits) compared to the patient group that did not have post-surgical product and lifestyle support.1 When paired with quality products as well, a large health system in the Midwest, reported an increase in patient satisfaction scores2. For more information on how Coloplast can impact outcomes, please contact your sales representative.

Read the full white paper here. ●

Information from Coloplast Care is for educational purposes only. It is not intended to substitute for professional medical advice and should not be interpreted to contain treatment recommendations. You should rely on the healthcare professional who knows your individual history for personal medical advice and diagnosis.

Citation: American Association for Homecare, United Ostomy Associations of America, Inc, United Spinal Association, Wound Ostomy and Continence Nurses Society, Wound, Ostomy and Continence Nursing Certified Board (2021). The Critical Need to Provide Ostomy Supplies Specific to Patient Need to Improve Health Outcomes

References:

1. Rojanasarot, S., The Impact of a Readily Available, Post-Discharge Support Program for Ostomy Surgery Patients on Preventable Health Care Utilization, JWOCN, 2018;45(1):43-49.

2. Helder, D., O’Day, M., Measuring System Impact by Improving the Ostomy Patient Experience from a Product Standardization Project in a 13-Hospital Integrated Delivery Network in the Midwest. JWOCN, 2017, 44(35): S53.

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